Clinical Judgement

FORTHELOVEOF!!!! · Apr 19, 2012

First, kudos to you for not listening to your instructor on that and getting another opinion!

Second, I have asked this question many times and the answer I typically get is, if BP is within normal limits, hold and call doc. If it is outside the normal limits give it, but I still ask because a BP that is just slightly elevated would make me second guess myself. I have heard from nurses that it's something you get more comfortable with the longer you are in the field but if anyone has certain perameters that their institution uses I would love to hear them as well.

allnurses Guide · Apr 19, 2012

The diastolic reading is pretty low.

How well are the tissues going to be perfused if there is not enough pressure between contractions?

I would not give it and call the doctor.

janieg44 · Apr 19, 2012

Thank-you. Do you mean that if the blood pressure is outside the normal limits, hold and call the doc?

In an elderly woman after surgery, it's better to be safe than sorry- that was my parameters but it would be great to have something more concrete to go on.

janieg44 · Apr 19, 2012

The diastolic reading is pretty low.
How well are the tissues going to be perfused if there is not enough pressure between contractions?
I would not give it and call the doctor.[/QUO
OK thanks. Better safe than sorry for a 92 year old.

FORTHELOVEOF!!!! · Apr 19, 2012

I mean if her blood pressure is within normal limits or lower, hold the med and call the doc to see where he wants to go from there. If higher than normal limits, give it. But I feel the same way, if it feels wrong, I'm not doing it.

janieg44 · Apr 19, 2012

Oh, yes, now I see what you mean.

MN-Nurse, ASN, RN · Apr 19, 2012

I feel that if I had listened to my Nursing instructor the patient may have been in trouble.

Good job asking more questions and using other resources.

I would also want to see the pt's VS the last time they were administered those meds and effect, if any, they had. Also consider the med class/mech of action of each of the two meds you were considering and think about why you would give or hold them.

You only gave one other BP reading. If the pt's VS had been stable for 24 hours, asymptomatic with a systolic of 132 and a MAP of 74, the pt would most likely have been fine if given the meds.

I would have been just fine holding those just to make the patient feel better without calling the doc. Depending on the patients fluid status/hx I might have held the calcium channel blocker and given the ACE inhibitor.

pghnurse527 · Apr 19, 2012

Good job with sticking to your guns and not just listening to your instructor. Instructors are humans as well, and they DO make mistakes. I have witnessed it myself. If you do not feel right about something, it is the patient's life at stake..speak up like you did! You can use MAP (mean arterial pressure) to help figure out if the organs are being properly perfused.

systolic + diastolic + diastolic / 3 =MAP

The normal MAP is around 70-110, your patient's was 74. I personally would want to double check with a physician before giving a BP med if my patient's MAP was only 74.

NCRNMDM, ASN, RN · Apr 19, 2012

I totally agree with what you did in this situation, and I have to say congratulations for getting a second opinion from the primary nurse before giving the medication. When I find myself in these situations, I do a number of things. First, I go to the computer, put in the vital signs I just took, and look at the trends for earlier in the day (I have night shift clinicals right now). I also look to see if the medication was administered on day shift, and what the BP was at that time. I then look to see what the BP dropped to after the medication was administered.

As another person mentioned, you can figure up the MAP, and really get a sense of how well the tissues are being perfused. I also calculate my patient's MAP in these situations. As the previous poster said, with an MAP of 74, I would not feel comfortable administering these medications.

After I've collected all my data, I report to the primary nurse. My little spiel goes something like this, "Mrs. X in room 100 has a BP of 130/45. Her other vitals are: x, y, and z, and her MAP is 74. I've looked at her vital sign trends, and when her BP med was administered last her BP was 150/85 (just an example I made up). After administering the BP med, her BP fell to 125/65 within one hour. Because of her low diastolic pressure, and because her MAP is on the low end of normal, I don't feel comfortable giving this medication. The patient also expressed concerns about receiving this med. I feel that we should withhold this dose, but I wanted to see what you thought was best."

At this point, I let the primary nurse make the decision because he/she has more knowledge and experience than I. I've alerted him/her about the current vitals, the trends, and the patient's feelings. I've given my input on the situation, and I've stated the course of action I find best for the patient. If the primary nurse tells me to give the medication anyway, I give it, but I make sure and tell my clinical instructor the exact same thing I told the primary nurse. I cover all of my bases, and I try to do what's best for the patient.

Pneumothorax, BSN, RN · Apr 20, 2012

Hi, I'm a Nursing and from New Jersey. I'm in my second semester and we had our clinical at a hospital yesterday. My patient, a 92 year old woman with a repaired hip fracture had a blood pressure of 130/45 and was due for Benazipril and Norvasc. I checked her last reading from her med. record and it was 139/43 2 1/2 hours earlier.
My patient (who was awake, alert, and oriented) said she was concerned about receiving her blood pressure medication because her diastolic pressure was so low. I agreed it was low and said I would talk to my Nursing professor before I came back with the meds in case the dose needs to be withheld or reduced.
My Nursing instructor then told me to "talk her into getting the medication." She said my job is to sell it to her.
I then went to the patient's primary nurse and explained the situation to her. She contacted the Dr. who withheld the meds for the day and had us monitor her BP more frequently.
My question is what is the guideline for withholding BP meds?
I need to know so that if this happens again I'll be more sure of myself.
I feel that if I had listened to my Nursing instructor the patient may have been in trouble.

Good job advocating for your patients safety! I don't think I would have felt comfortable giving a bp med with such a low diastolic. It just seems a bit wonky.

Were those pressures taken manually or with the automatic machine? I go into the chart & check what the pressure was that am then i take my own manually & see if they match up.

I don't like how ur instructor said to force it on them err "sell it" if u did U would have had a potentially very serious issue.

Good job!

zofran · Apr 20, 2012

I mean if her blood pressure is within normal limits or lower, hold the med and call the doc to see where he wants to go from there. If higher than normal limits, give it. But I feel the same way, if it feels wrong, I'm not doing it.

If the patients blood pressure is normal you don't have to hold the medication. The BP med is keeping the blood pressure normal. The doctor would not want to be called about holding a BP med for a normal pressure.Good job OP for checking with the primary RN. Your teacher seems weird. Our job is not to "sell" the patients into taking their meds in this situation.